Provider Demographics
NPI:1245695550
Name:LINE, KRISTYN (ARNP)
Entity type:Individual
Prefix:
First Name:KRISTYN
Middle Name:
Last Name:LINE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W STATE ROAD 434
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5119
Mailing Address - Country:US
Mailing Address - Phone:321-842-2994
Mailing Address - Fax:407-767-5801
Practice Address - Street 1:555 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5119
Practice Address - Country:US
Practice Address - Phone:321-842-2994
Practice Address - Fax:407-767-5801
Is Sole Proprietor?:No
Enumeration Date:2015-12-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9315039363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016505200Medicaid